Several years ago, my wife Uzma was diagnosed with stage 3 breast cancer. She went into remission after surgery, chemotherapy, and radiation. A year and a half later, the cancer came back. This time, in her liver. She lived three more years after that, and those three years involved a lot of care — including a lot of MRIs.
Once, after our health insurance company approved one of her MRIs, a nurse from the insurance company called.
After some preliminary conversation, she said to Uzma, “I am calling to tell you about an option you have for your approved MRI. You can get it done without a copay.”
“How’s that?” asked Uzma.
“If you go to Hospital B instead of Hospital A for the MRI, you would have no copay.”
Hospital A was just two miles away from our home. It is where Uzma got all her cancer care. Hospital B was a 45-minute drive away (each way), and she had never received care there before.
“Is Hospital A out-of-network now?” she asked.
“No, Hospital A is still in-network, and you can still get your MRI there,” the nurse went on. “We have a contract with Hospital B, due to which they don’t charge copays to our members.”
“But I don’t know anyone there. And it’s a commute to that place.”
“I understand.”
“And none of my doctors are there. I will have to make sure they get my records. Here, they can see everything within the same system.”
“I understand,” the nurse said, explaining, “we just wanted you to know about the zero-copay option.”
Thanking her, Uzma ended the call.
Uzma didn’t take the cheaper option. She didn’t think the extra burden of making sure every one of her doctors could still get her records easily was worth what she’d save. As a physician herself, she knew the value of keeping all her care under one roof more than most others would.
I work in health insurance now. I understand exactly why they made that call. Managing cost is a legitimate, necessary part of running a health system. And it would have saved my wife, the patient, money too. A different patient, even with the same illness, might reasonably have chosen Hospital B. Uzma, in the middle of a complicated, high-stakes, multi-provider fight against metastatic cancer, made a different calculation.
What I appreciate about the insurance company in this case was that they left it up to Uzma. Standardizing the choice into one default — take the free option, it’s the same MRI, it will save you money, it will save us money — would have cost Uzma something the insurance company had no way to see on their end of the line: the ease with which the people keeping her alive could find what they needed, when they needed it.
She was, in effect, offered the chance to pay and let her doctors pay, a non-monetary price, in exchange for less money upfront. She said no, and paid the copay herself instead. That choice protected this load-bearing wall.
Where the Argument Stands
Some variation in healthcare is preventable and worth preventing: a missed step, a treatment that should have been given and wasn’t. Standardize that away without hesitation. I meant every word of Post 2, The Standardization Tax, Part 2: When Standardization Works.
Some variation is preventable but load-bearing. It comes in at least two forms. One is built on what a patient wants — different people, same diagnosis, different circumstances, different legitimate answers. The other is built on what a physician, or in Uzma’s case, an entire care team, has learned about a specific patient over time. Standardize either one away without checking what it’s holding up, and something specific collapses.
When a load-bearing wall comes down, somebody pays. It isn’t always the same somebody, and it isn’t always in the same currency.
That’s The Standardization Tax.
Not everything that can be counted counts, and not everything that counts can be counted.
— William Bruce Cameron, Informal Sociology (1963)
What Physicians Pay
Go back to the last post’s hospitalist, rotating on and off a case every few days. Every time a physician picks up a patient mid-course, they do invisible work that used to be unnecessary — reconstructing context, guessing at intentions behind decisions they didn’t make. That’s not charted anywhere. It’s not billed.
Physicians, as a group, don’t like being handed problems we didn’t create and weren’t warned about. We chose a profession built on healing people. The prior shift’s undocumented reasoning does not care about our feelings on this.
Go back to the same post’s other load-bearing wall — the shared decision-making Wennberg said preference-sensitive care actually requires. That conversation takes time, and most physicians’ work output is measured by volume, not by how well they helped a patient understand a genuinely hard choice. A ten-minute visit doesn’t leave room for it. So physicians either have the conversation anyway, on their own unpaid time, running the rest of the day behind, or they don’t, and something gets decided faster than it should.
Either way, the tax comes out of the physician’s own reserves. That’s not the whole story of burnout. But it’s a real, specific, and rarely counted piece of it.
What Patients Pay
The other bill goes to the patient, and it shows up differently depending on which load-bearing wall came down.
When a care team’s shared knowledge gets fragmented, the patient pays through the reconstruction gap — a medication continued at a dose nobody currently treating them can fully explain, a diagnosis made without its supporting findings, because whoever made it moved on. Care doesn’t stop. It just gets a little less precise every time someone has to start over. Uzma understood this well enough to pay a copay to avoid it.
When a patient’s preference is standardized, they pay through a decision that was never really theirs — because nobody had the ten extra minutes to help them choose otherwise.
What’s Worth Keeping in Mind
The wrong lesson here is that since the system won’t give you enough time, you should make up the difference yourself. Absorb it. Be the hero who quietly compensates for every gap the schedule creates. That’s not resilience. That’s the exact mechanism that produces burnout, just relabeled as virtue.
The right lesson is about scope, not sacrifice.
When you’re an ER doctor, you don’t try to get a diabetic patient’s blood sugar under perfect long-term control during their visit for a broken wrist. You focus on what keeps them safe today, and you refer the rest to the person whose job it is to manage it over months. That’s not a lesser standard of care. It’s the correct standard of care for what an ER visit is actually for.
The same logic applies to a ten-minute appointment. If that slot was built for a focused problem, don’t quietly try to turn it into a comprehensive physical, no matter how much you’d like to. You’ll do neither well, and you’ll leave the room feeling like you failed at something you just didn’t have space for.
Do the focused problem well. And inside those same ten minutes, you can still look the patient in the eye, ask one real question, and let them know you’re paying attention to them as a person, not just a chief complaint. Nobody can standardize your attention away unless you let them.
You cannot personally fix the reimbursement model between now and Tuesday’s clinic. You can control what happens inside whatever room you’re actually in. Those are two very different jobs, and confusing them is how good doctors burn out trying to do both at once.
What is essential is invisible to the eye.
— Antoine de Saint-Exupéry, The Little Prince
Back to That Pre-Med Student
The med student that I imagined back in Post 1 — if you are still reading this, here’s what you must know: The system you’re walking into has real problems. Documentation eats hours that used to belong to patients and to physicians. Visits are shorter than the conversations they’re supposed to hold. Fragmentation of care, ironically, often comes directly from standardization efforts sold as improvements.
Unlike many doctors, I wouldn’t discourage you from medicine. I’d tell you that it is still one of the few professions that is purpose-driven. I’d tell you that it is still a profession where you can do well while doing good. I’d tell you that it is still a profession where the crucible of the job builds amazing friendships over the years. But I’d tell you to walk in with your eyes open, know exactly which parts of the job are yours to protect, and refuse to confuse “I couldn’t fix the whole system today” with “I failed my patient today.”
Most days, you’ll have done neither. You’ll have done your actual job, in the room you were in, with the ten minutes you had.
That’s the Standardization Tax.
It’s rarely visible on the spreadsheet that justified removing preventable but load-bearing variation. And it always, eventually, gets collected from someone.
The One Practice
Take the process you named at the end of Post 1, The Standardization Tax: Not Every Tradeoff Is Worth It — the one you were asked to keep in mind. Now ask the harder question: if it removed preventable variation that was a load-bearing wall, who has been quietly paying for that, and have they had any way to say so?
This post is Part 4 of a four-part series in which I explore where standardization helps in medicine, where it costs us something important that cannot be measured, and how patients and doctors pay the price that I call the Standardization Tax.
